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Professional development and practice support for self care SUBSCRIBERS JUNE 2013 Colds and flu V ol .14 Number 5 Print Post approved PP255003/05274 QCPP Approved Refresher Training (Counter Connection) John Bell says Contents JUNE 2013 V ol .14 Number 5 Managing editor Andrew Daniels Production coordinator Kylie Davis Contributor Jan Castrisos Peer Review Marnie Firipis Layout Caroline Mackay This publication is supplied to subscribers of the Self Care program. For information on subscribing to the program, contact PSA at the address below. Advertising policy: inPHARMation will carry only messages which are likely to be of interest to all members of the Self Care program and which do not reflect unfavourably directly or by implication on the pharmacy profession or the professional practice of pharmacy. Messages which do not comply with this policy will be refused. Views expressed by authors of articles in inPHARMation are their own and not necessarily those of PSA, nor PSA editorial staff, and must not be quoted as such. The information contained in this material is derived from a critical analysis of a wide range of authoritative evidence. Any treatment decisions based on this information should be made in the context of the clinical circumstances of each patient. PSA3844 ISSN: 2201-3911 Photographs in non-news articles in inPHARMation are for illustrative purposes only and the models appearing in these photographs should not be presumed to endorse any product mentioned in the article or suffer from any condition mentioned in the article. Influenza (flu) and the common cold are both viral infections involving the upper respiratory tract. See page 04, Facts Behind the Fact Card: Colds and flu Pharmacist CPD 04 Facts Behind the Fact Card: Colds and flu Pharmacy assistants’ education 12 Counter Connection: Colds and flu Regulars 03 16 John Bell says Members’ noticeboard Subscribe to inPHARMation Self Care contacts Your staff can have their own copy mailed directly to them at home or work. To contact your local branch phone 1300 369 772 Membership enquiries: 1800 303 270 Email: [email protected] Additional inPHARMation 12-month subscription $90.00 inclusive of GST. Self Care inPHARMation Subscription PO Box 42 DEAKIN WEST ACT 2600 Enquiries – Ph: 02 6283 4777 Self Care Fact Cards Pharmaceutical Society of Australia Ltd. ABN 49 008 532 072 Pharmacy House PO Box 42, Deakin West ACT 2600 P: 02 6283 4777 » F: 02 6285 2869 E: [email protected] www.psa.org.au Sponsorship For sponsorship and advertising enquiries contact the Sponsorship Manager, Tony Craig on (02) 9547 3001 or [email protected] Please make sure that you keep your Fact Cards up to date. You can re-order any Fact Card title at any time. Simply ring 02 6283 4777 or fax your order to 02 6285 2869 or go to Self Care at www.psa.org.au/selfcare Display units Fact Cards are included in your subscription. Email:[email protected] The Plastics Factory Pty Ltd (ABN: 62-128-887-767) Ph: 1800-OZPLASTICS (1800-697-527) Fax: 1300-OZPLASTICS (1300-697-527) Web: www.plasticsfactory.com.au/psa/psa.htm © Pharmaceutical Society of Australia Ltd., 2013 This magazine contains material that has been provided by the Pharmaceutical Society of Australia (PSA), and may contain material provided by the Commonwealth and third parties. Copyright in material provided by the Commonwealth or third parties belong to them. PSA owns the copyright in the magazine as a whole and all material in the magazine that has been developed by PSA. In relation to PSA owned material, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968 (Cth), or the written permission of PSA. Requests and inquiries regarding permission to use PSA material should be addressed to: Pharmaceutical Society of Australia, PO Box 42, Deakin West ACT 2600. Where you would like to use material that has been provided by the Commonwealth or third parties, contact them directly. 2 inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. John Bell says Coping with common colds By John Bell, Self Care Principal Adviser We’re frequently asked to provide products for, and advice about, colds and flu. So much so that products in the cough/cold category are the most commonly requested in the non‑prescription department in pharmacy. However, it’s the category in which there seems to be the least satisfaction amongst customers. There are probably a number of reasons for this. Firstly, despite our customers’ expectations, there is no miracle cure for a cold or the flu; the best we can provide is good symptomatic treatment. Secondly, and quite significantly, some of the products which can be self selected don’t always measure up to the claims that are made for efficacy (it’s worth taking the time to recommend the more effective S3 products). Also, it’s important that we (and our customers) are able to distinguish between a cold and the flu. By far most customers who stagger into our pharmacies sniffling, sneezing and coughing will have a cold – not the flu. If they really had the flu with its more sudden onset of symptoms – headache, general aches and pains, exhaustion and fatigue – they’d have trouble leaving the house and getting to the pharmacy. Of course, some hardy customers do ‘soldier on’ into the pharmacy, regardless of the severity of their symptoms; so the table on page 13 of Counter Connection will help you differentiate between these conditions. The What Stop Go protocol (see page 14) will also assist in choosing the right product to recommend. As we know, these infections are caused by viruses, so antibiotics are not effective (the presence of yellow/green mucus is not necessarily an indication of a bacterial infection, it’s simply an indication that our immune system is doing its job). And this is a message we need to reinforce to our customers. Taking antibiotics inappropriately only serves to increase antibiotic resistance both in the community and in the individual. There are antiviral prescription-only medications for the flu (Tamiflu and Relenza), however their beneficial effect is limited and they need to be used at the first onset of symptoms. Page 9 gives more details. We have a role to play in promoting prevention of these (mostly) wintery infections; by way of advocacy of general hygiene measures and flu vaccination for those at risk. There are many myths and misconceptions about flu vaccination and these are raised in Practice Point 4 on page 8. The safety and efficacy of cough/ cold products for children is another important issue which is addressed in this inPHARMation. Ear, Nose & Throat 1117 2011 Coughs Ear, Nose and Throat 0086 2011 The common cold, allergy and cigarette smoke are common causes of coughing, but a cough can also be a symptom of a serious illness or a side effect of a medicine. Treatment for a cough depends on its cause. Cold and Flu Coughingisanormalreflextoprotect and clean our airways (respiratory tract). Coughingclearsirritatingmaterial(e.g., smokeordust)andexcesssecretions (mucus,sputum,phlegm)fromour throat,airpassagesandlungs.The sound and pattern of a cough depends on its cause. Causes of coughing Cough is a symptom of a range of medical conditions and sometimes a person may have more than one reason for coughing. Causes of coughing include: •Postnasaldrip(catarrh)–excessnasal secretions which run down into the backofthethroat.Oftencaused byallergy,commoncoldsorsinus infection Common colds and the ‘flu’ (influenza) are viral infections affecting the nose, sinuses, throat and airways. Antibiotics do not work against these viral infections, but colds and the flu usually get better on their own. Medicines may relieve some of the uncomfortable symptoms of colds and flu. •Asthma When someone has a cold or flu, •Respiratorytractinfections(e.g.,colds, the fluid from their nose, mouth bronchitis,croup,whoopingcough, and airways contains the infecting pneumonia) virus. Colds and flu spread when this •Inhaledirritants(e.g.,cigarettesmoke, infected fluid passes to someone-else dust,fumes,aforeignbody) (e.g., by touch, coughing, sneezing). •Lungdisease(e.g.,cysticfibrosis, Colds spread easily, especially between COPD,cancer) children who spend a lot of time •Gastroesophagealreflux(heartburn) together (e.g., at childcare or school). –Astomach acidinfectious rises up into thefirst one cold is most in the oesophagus coughing or two days and aftertriggers symptoms develop. Signs and symptoms Self Care is a program of the Pharmaceutical Society of Australia. symptoms include: Self Care is committed to providing currentCold and reliable health information. •Runnynose •Blockednose(congestion) •Sorethroat •Red,wateryeyes •Sneezing •Coughing •Mildfever •Headache •Tiredness. Flu (influenza) symptoms are similar to cold symptoms, but are usually more severe and may also include: •Highfevers,sweatingandshivering •Achingmusclesandjoints •Weaknessandlethargy •Lossofappetite,nauseaandvomiting. Cold and flu symptoms usually go within 10 days, although a cough may last longer. Protection against influenza A‘fluinjection’willgiveprotection againstthe‘flu’.Vaccination,before the‘flu’seasonstartseachyear,is Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. Electronic delivery The John Bell Health Column is available weekly by email. If your pharmacy would like to receive the column, please send your email details to [email protected] This course helps you to: » Coordinate Home Medicines Reviews » Manage people » Assist to dispense prescriptions » Coordinate pharmacy health promotions » Maintain and order stock PSA3791 Get ahead with PSA’s Certificate IV in Community Pharmacy P: 1300 369 772 » [email protected] » www.psa.org.au inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 3 John Facts Bell says Behind the Fact Card Colds and flu Pharmacist CPD Module number 238 By Jan Castrisos up to Colds and flu 2 CPD Credits GROUP 2 This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. Influenza (flu) and the common cold are both viral infections involving the upper respiratory tract. Because they share many symptoms, people often use the terms cold and flu interchangeably. More than 200 different viruses can cause the common cold including rhinoviruses and adenoviruses. Learning objectives After reading this article, the pharmacist should be able to: • Compare and contrast the pathophysiology and symptoms of the common cold with those of influenza. • Differentiate between patients with the common cold and influenza. • Understand the Therapeutic Goods Administration changes to the guidelines for managing cough and colds in children. • Describe treatment regimens and provide advice for the management of the common cold and influenza. Competencies addressed (2010): 1.1, 1.2, 1.3, 2.2, 2.3, 6.1, 6.1, 6.2, 6.3, 4 Colds and influenza Risk It is important to know the difference between a cold and the flu to effectively advise customers. Colds are very common – adults can get two to four colds per year while children can get as many as three to 12.1 Everyone is at risk of getting a cold or flu; however, because there are a variety of situations and circumstances, some people are at increased risk. Those at increased risk include:3,4 Respiratory tract infections (RTIs) are the most common acute problem dealt with in primary care. Hence it is essential that pharmacists have a thorough knowledge of the symptoms to ensure any differential diagnosis is not missed.2,3 The widespread prevalence of the common cold and the multitude of symptoms affecting the individual, coupled with the ever-increasing array of single-agent and combination products available for treating them, can lead to a great deal of patient confusion and inappropriate or even dangerous self-medication. Although colds are generally not serious; babies, the elderly and anyone whose immune system is compromised can be at risk of developing more serious complications. inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. • newborns • young children, especially those in day‑care or preschool • people with underlying chronic diseases such as asthma and cardiac disease • immunocompromised individuals (e.g. chemotherapy patients) • people living in shared accommodation such as boarding schools and nursing homes • elderly people >65 years of age • Aboriginal and Torres Strait Islander people aged 15 years and over.5 Epidemiology The common cold is an acute, self-limiting viral infection involving mucous membranes of the upper respiratory tract. More than 200 different viruses can cause the common cold including rhinoviruses and adenoviruses. About 30% to 50% of all colds Colds and flu are caused by one of the many rhinoviruses: they occur all year round.3,4 Flu is an acute infectious RTI caused by influenza viruses A, B and C of the family Orthomyxoviridae. The Type A viruses are the most virulent human pathogens amongst the three influenza types and cause the most severe infections. Influenza A also has a high propensity for antigenic change, allowing it to escape recognition by the body’s immune system. This antigenic change uses an avian intermediate host (IH) causing epidemics and pandemics. In particular, Type A viruses have a remarkable ability to undergo periodic changes in the antigenic characteristics of their envelope glycoproteins, the haemagglutinin and the neuraminidase. Among the influenza Type A viruses that infect humans, three major subtypes of haemagglutinins (H1, H2, and H3) and two subtypes of neuraminidases (N1 and N2) have been described. Influenza Type B viruses have a lesser propensity for antigenic change, and only antigenic drifts in the haemagglutinin have been described. Most cases of flu occur within a 6–8 week period around winter and spring. Type B causes a similar, though possibly milder infection than Type A. It can cause epidemics but has no intermediate host. Influenza Type C does not cause epidemics and causes only mild infections. Influenza epidemics occur, on average, every three years. Influenza pandemics have occurred four times in the past 100 years and can cause many deaths.3,4,6,7 Virus strains are eventually named according to influenza virus type, the town where the virus was first isolated, number of isolates, year of isolation and major type of important proteins e.g. Influenza B/Hong Kong/330/2001. Pharmacist CPD Module number 238 the influenza virus, the rhinovirus can also be transmitted using this route. The importance of large particle droplets caused by sneezing or coughing is less well documented. • Direct contact with infectious secretions. Some viruses may be spread by hand contact (e.g. shaking hands, telephone handles) then autoinoculation through contact with the nose or eyes. • The main reservoir of viruses is in young children. They are more susceptible because of the lack of antibodies as well as having a larger concentration of the virus in secretions. Most commonly, transmission occurs in the home, in schools, and in day-care centres where very young children are in close regular contact with each other and their carers. The incubation period varies depending on the causative virus. It is usually 1–2 days for the rhinoviruses and three days for the coronaviruses, but people can remain infectious for several weeks.4,6,8 Facts Behind the Fact Card Practice point 1 Medications that may cause a chronic cough • Ace inhibitors – dry persistent cough develops in the first month of therapy in a minority of people as a side effect. Some examples are: -- enalapril -- ramipril -- perindopril -- captopril. • Beta-blockers – dry persistent cough develops in the first month of therapy in a minority of people as a side effect. Some examples are: -- propranolol -- atenolol -- carvedilol -- oxprenolol. Transmission of the influenza virus • Transmission of the influenza virus occurs by smaller particle droplet inhalation and usually affects the upper respiratory tract. The virus reproduces within the epithelium and destroys the cilia. The incubation period of the influenza virus is 1–3 days after the onset of symptoms.6 Symptoms and diagnosis Common cold Many people will come into the pharmacy for advice regarding the common cold. Transmission Transmission of the common cold Transmission of the common cold varies depending on the type of virus implicated. The following three transmission routes are recognised: • Inhalation of airborne respiratory droplets from people infected with the virus. Small particle droplets linger in the air and are highly contagious. Although this is the more common route of transmission of Related Fact Cards Colds and flu Coughs Ear problems Sinus problems Pain relievers inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 5 John Facts Bell says Behind the Fact Card Practice point 2 Antibiotic use for cold and flu15 Overuse and misuse of antibiotics is making it harder to treat bacterial infections and antibiotics are losing their power against illness causing bacteria. The World Health Organization has recently declared antibiotic resistance ‘one of the greatest threats to human health today’. Pharmacists have an important role in helping to address this problem by counselling customers about the ineffectiveness of antibiotics for the treatment of viral infections. Direct customers to the NPS Medicinewise website for information regarding the irrelevant use of antibiotics for a viral infection. Points to make are: • Antibiotics are only effective against bacteria and not viruses – colds, flu and most coughs are caused by viruses and will get better on their own. • Cold and flu symptoms should be treated and the immune system can fight the virus – antibiotics will not help you get better quickly, and may give you side effects such as diarrhoea and thrush. Antibiotics won’t stop your virus spreading to other people. • Don’t take someone else’s antibiotics. • Take antibiotics only as directed, if prescribed. • Practise good hygiene to help stop the spread of germs. Pharmacists should refer a customer to the doctor if they suspect that he or she has a secondary bacterial infection or if the person is a high risk category for complications. (See complications page 8) 6 Colds and flu Pharmacist CPD Module number 238 A predictable sequence of symptoms is as follows: • A ‘scratchy’ or sore throat appears first and usually resolves quickly. • Nasal obstruction (i.e. congestion) and rhinorrhoea predominate by day two or day three. • Nasal secretions are initially clear, thin and watery. • Cough appears by day four or five although it develops in fewer than 20% of people. Temperature is usually normal, particularly when the pathogen is a rhinovirus or coronavirus. However cold symptoms in a baby or child may include increased body temperature. Most symptoms due to uncomplicated colds resolve within seven to 10 days but some symptoms may occasionally last 2–3 weeks. Diagnosis is based on clinical signs and symptoms and exclusion of more serious illnesses. Viral cultures or specific diagnostic testing are unnecessary as the common cold is self-limiting. People with asthma are not at greater risk of rhinovirus infection compared to healthy individuals, but they do suffer from more frequent lower respiratory tract (LRT) infections and have more severe and longer‑lasting LRT symptoms. The presence of LRT symptoms such as wheezing can effectively exclude the common cold. Complications of the common cold can include sinusitis, bronchitis, and bacterial pneumonia, exacerbation of asthma or Chronic obstructive pulmonary disease (COPD) and middle ear infections. Most people do not develop complications from colds. When complications do develop they may be severe but rarely life threatening. The elderly are at risk of more serious life threatening complications if infected by the influenza virus and this disease must be distinguished from the common cold. Table 1 indicates the general differences between the common cold and influenza.6,10,12 Influenza Infection with influenza is characterised by a sudden onset of: • • • • • • • • fever chills severe malaise myalgia (especially in the back and legs) dry cough nasal obstruction dry sore throat headache (often with photophobia). Respiratory symptoms may be mild at first but as the infection progresses, LRT illness becomes more dominant, with a persistent raspy, productive cough. Fewer virus particles are required to infect the LRT compared to the upper respiratory tract (URT). Cough, weakness, sweating and fatigue may persist for several days or occasionally for weeks. Children may have higher temperatures, as well as nausea, vomiting or abdominal pain, and infants may present with a sepsis-like syndrome (e.g. diminished spontaneous activity, less vigorous sucking, apnoea and temperature instability).6,11 Treatment Common cold There is no magic cure for the common cold. Treatment aims to ease symptoms, improve daily functioning and prevent the spread of disease to others whilst the immune system clears the virus. Table 1. Influenza or the common cold?9,10,11 Symptom Common cold Influenza Spectrum of illness Local – nose and throat Systemic Speed of onset Gradual Sudden Fever None to mild Usually high – lasts 3– 4 days General aches None to slight Usual – often severe Fatigue and weakness Mild Usual – may last 2–3 weeks Headache None to mild Prominent Exhaustion Rare Early and prominent Stuffy nose Common Sometimes Sore throat Sometimes Common Sneezing Usual Sometimes Cough, chest discomfort Mild Common, can become severe inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. Colds and flu Children The Australian Therapeutics Goods Administration (TGA) has for some years been carrying out a comprehensive review of the safety and efficacy of over-the-counter (OTC) cough and cold preparations for the treatment of cough and cold symptoms in children less than 12 years of age. The TGA has concluded that there is currently a lack of evidence of efficacy for OTC cough and cold medicines in children aged less than 12 years of age and the historical profile of adverse reactions indicates that there are potential risks involved in using these medicines in children. The risks are greater in children aged less than six years compared to those aged between six and 11 years. Therefore, the TGA has said that these medicines should not be used for treating children under six years of age, and that they should only be administered to children aged 6–11 years on the advice of a doctor, pharmacist or nurse practitioner.13 The first indication of a common cold in a baby or toddler is often a congested or runny nose. Nasal discharge may be clear at first, but then usually becomes thicker and turns shades of yellow or green. A baby’s immune system needs time to conquer the cold. If the baby has a cold with no complications, it should resolve within a week.14 Babies younger than 2–3 months of age should be referred to the doctor early in the illness. In newborns, the common cold can quickly develop into croup, pneumonia or another serious illness. Even without such complications, a stuffy nose can make it difficult for babies to breast feed or drink from a bottle. This can lead to dehydration. The TGA review found that while there are no immediate safety risks with these products, there is evidence that they may cause harm to children and the benefits of using them in children have not been proven. On 1 September 2012 the following changes were made to the recommendation for the sale of cough and cold medicines in children. • Cough and cold medicines should not be given to children under six years of age • Cough and cold medicines should only be given to children aged 6–11 years of age on the advice of a doctor, pharmacist or nurse practitioner Pharmacist CPD Module number 238 Cough and cold medicines used for treating children that contain at least one of the below active ingredients are affected by the changes. Type of medicine Active ingredients antihistamines brompheniramine chlorpheniramine dexchlorpheniramine diphenhydramine doxylamine pheniramine promethazine triprolidine antitussives codeine dextromethorphan dihydrocodeine pentoxyverine pholcodine mucolytics/ expectorants bromhexine guaifenesin ipecacuanha senega and ammonia decongestants Facts Behind the Fact Card Practice point 3 PDL advice on TGA recommendations A media poll in Pharmacy News 12 March 2013 suggested around 40% of pharmacists would probably supply cough and cold medicines to children less than six years old believing that there are no safety risks with these products. As reported in Pharmacy News 12 March 2013 Albert Regoli (director of PDL) issued the following warning on the topic of OTC cough and cold changes for children under six: phenylephrine pseudoephedrine oxymetazoline xylometazoline These medications may still be recommended for any other approved indication. According to the Approved Product Information (eMIMS), other approved indications for promethazine (Phenergan) for example, are allergies, nausea and vomiting, sedation and ‘other’ (e.g. symptomatic management of chickenpox). Phenergan does currently have a dose recommendation for 2–5 year olds for allergy, sedation, travel sickness, nausea and vomiting. Always check the literature before recommending any of these medications for children for indications other than for cough and cold treatment. Most useful advice The most useful advice especially for children up to the age of 11 years is: • The child should stay home and rest. • The use of paracetamol or ibuprofen for fever, sore throats, aches and pains. • A fever can lead to mild dehydration due to sweating, causing tiredness and headache. Advice is to drink plenty of fluids such as water, fruit juices and clear soups. • Steam inhalations (e.g. humidifiers) help clear mucous and clear a blocked nose. It is a temporary effect, but may be useful before bedtime (especially for children) to help them get off to sleep. ‘Pharmacists owe a duty of care to take reasonable steps to avoid foreseeable risks of injury to others, so in the case of supplying cough mixtures, that duty of care extends to children, and particularly young children become even more of a risk,’ he said. ‘If a pharmacist knowingly supplies a cough mixture to a child under the recommended age and the child does suffer some damages as a result, there is going to be a possible case for negligence.’ However, Mr Regoli said the mere supply of medicine did not necessarily mean a pharmacist had breached their duty of care as other factors came into it. These factors may include: (but not limited to) • whether a doctor was involved in the recommendation • whether the pharmacist knew or should have known that a child would consume the medicine • the quality of the warnings that the pharmacist disseminated at the time of the medicine supply • the unique characteristics of the child. inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 7 John Facts Bell says Behind the Fact Card Practice point 4 Immunisation Immunisations should be current. There is no vaccine against the cold, but encourage those at risk to ask their doctor about the flu vaccine, pneumonia vaccine as well as tetanus, diphtheria and whopping cough booster. (See The Australian Immunisation Handbook 10th edition 2013 for an update). Myths about the flu shot 1.The flu shot causes the flu. The truth is that a flu shot takes up to two weeks to become effective; so if a person gets infected before the vaccine has had enough time to work, they will fall sick. 2.It’s too late to get vaccinated if you have already had the flu this year. The flu vaccine is designed to protect against multiple strains of the influenza virus. It is possible to get the flu more than once, each time caused by a different strain. Even if you have had the flu, a vaccine can still protect against other strains of the virus. 3.Flu shots are 100% effective. The truth is you can still fall sick with the flu even after being vaccinated. However, it has been found that vaccinated people are 62% less likely to get the flu and are at far lower risk of requiring medical care if they do get sick. 4.People who are allergic to eggs can’t get a flu shot. Flu shots are risky only if you have severe egg allergies. Most people who have egg allergies are not at risk of any complications with a flu shot. Side effects are mild, such as hives or itchy skin. Colds and flu Pharmacist CPD Module number 238 • Saline nasal sprays or drops (e.g. Fess, Narium) may help thin nasal secretions while avoiding the risk of rebound congestion due to decongestant nasal sprays. They are a good alternative for young children and babies especially just before feeding. What about cold remedies for children over six years and adults? There are many cold remedies in the pharmacy that can relieve symptoms. Remember, cold remedies often contain several ingredients. Some cause drowsiness, which may be welcome at bedtime when the customer indicates difficulty sleeping as a symptom. As some products contain paracetamol, be careful not to recommend more than the maximum safe dose of paracetamol if the customer is taking paracetamol tablets. It is possible that a customer may have a contraindication to many of the products available in the OTC cough and cold area of the pharmacy. It is imperative for pharmacists to accurately assess the customer by asking about the most distressing symptom and gather other essential background information, such as other conditions and medications. If the patient is deemed clear of any contraindications then the pharmacist can formulate an individualised treatment plan. Gathering information Pharmacy staff should gather appropriate information background as follows: 1.Description of the symptoms including when they started and the severity. 2.Familiarisation with relevant patient history such as age, weight and height (often obvious) and occupation to help with recommendations. 3.Medication allergies or adverse reactions to medications. 4.Current medical conditions as well as current medications both prescription and OTC. Complications An awareness of alternative or underlying diagnoses should be considered if: • A sore throat is the main symptom (streptococcal tonsillitis should be considered, especially if the patient is younger than 15 years of age). • Rhinitis has been present for more than 14 days (e.g. allergic rhinitis). 8 inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. • The illness started suddenly with fever, chills, and severe muscle aches (e.g. influenza or pneumonia). • The patient has pleuritic pain, large amounts of sputum or blood in the sputum (e.g. pleurisy or pneumonia). • There is an earache (e.g. otitis media) or there is facial pain (e.g. sinusitis). • Features of meningism are present (such as altered consciousness, photophobia, hypotonia, neck stiffness, seizures, and tachycardia). • Asthma, COPD, congestive heart failure, type 1 or type 2 diabetes, heart disease or other long-term (chronic) medical conditions exist. • The customer is frail and of advanced age. • The customer has a fever (a temperature of 38.5°C or higher) and is feeling unwell (e.g. a painful headache or stomach pain) and has not responded to paracetamol or ibuprofen. • There is worsening of symptoms during self-treatment. • The customer is on immunosuppressant therapy. • Rash exists with a fever (e.g. measles or chicken pox). • The customer complains of shortness of breath, tiredness and lack of energy. OTC cough and cold medicines As already stated there is no cure for the common cold and treatment is recommended to relieve symptoms. Analgesics Simple analgesics such as paracetamol, ibuprofen or aspirin may relieve fever, headache, sore throat and sinus discomfort. • Paracetamol is the analgesic of choice, as it has fewer adverse effects. • Ibuprofen should not be used in babies under 6 months of age. • Aspirin should not be given to children under 16 years old due to the risk of Reye’s syndrome. • Aspirin should be avoided during breastfeeding due to the theoretical risk of Reye’s syndrome in the infant. • Asthmatics should avoid aspirin and ibuprofen as they may precipitate bronchospasm in some asthmatics. • People with heart disease and peptic ulcer or a history of gastric bleeding should avoid aspirin or ibuprofen. Colds and flu Pharmacist CPD Module number 238 Influenza Decongestants Cough medicines Decongestants are the medicines of choice for a blocked or stuffy nose. They can be taken orally or in the form of nasal sprays or drops. Cough medicines are either mucolytics, expectorants or suppressants. They have questionable efficacy, particularly in acute cough associated with upper respiratory tract infections (URTIs). Oral decongestants (e.g. pseudoephedrine, phenylephrine) and nasal sprays or drops (e.g. oxymetazoline, phenylephrine, and xylometazoline) may be taken on an “as needed” basis for short term relief of rhinorrhoea and nasal congestion. • Evidence of benefit in children under 12 years is unclear. • Use of these preparations in children under 6 years is contraindicated. • Topical nasal decongestants are more effective than oral decongestants, but their use for more than 3 to 5 days may result in rebound congestion. • Oral decongestants should be used with caution in patients with diabetes, heart disease, hypertension, prostatic hypertrophy and hyperthyroidism.16 Antihistamines Antihistamines are classed as sedating and less-sedating. • Sedating antihistamines also known as first generation antihistamines (e.g. chlorpheniramine, dexchlorpheniramine, diphenhydramine, promethazine) may help to relieve a runny nose but can cause sedation and drowsiness. The use of antihistamines is controversial. Histamine does not play a role in the pathogenesis of the common cold. First generation antihistamines possess anticholinergic action that may reduce nasal secretions. These products are S3 and must be recommended by the pharmacist. They should be avoided in the elderly and people with benign prostatic hypertrophy or glaucoma. • Less-sedating antihistamines (e.g. loratadine, cetirizine, desloratadine) are indicated for allergic rhinitis and are not effective for treating the symptoms of a cold. Other drugs for rhinitis The intranasal anticholinergic ipratropium bromide may improve rhinorrhoea but should also be avoided in the elderly and people with benign prostatic hyperplasia or glaucoma. Facts Behind the Fact Card Mucolytics (e.g. bromhexine) reduce mucous viscosity and aid its expectoration. Although they are marketed for this purpose the evidence of efficacy for cough with URTIs is limited. Suppressants (e.g. codeine, dextromethorphan, dihydrocodeine, pholcodine) are meant to decrease coughing. Because coughing is a natural response to substances in the lungs they should be avoided in people suffering from certain airways diseases especially in children. Prevention Influenza is an important vaccinepreventable disease that causes illness in people of all ages. Annual influenza vaccination is important to help maintain immunity to influenza. The National Centre for Immunisation Research and Surveillance for Vaccine Preventable Diseases at the Children’s Hospital Westmead found hospital admissions of children with the flu were highest in children aged less than five years of age. The Australian Immunisation Handbook 10th edition 2013 has updated its recommendation as follows: Contraindicated in people with respiratory failure, asthma or COPD.17 Expectorants (e.g. guaifenesin) are used with the aim of promoting expectoration of bronchial secretions in productive cough. It remains unclear whether cough products offer any benefit in relieving coughs associated with a cold. Combination products containing expectorants and suppressants should be avoided. In many instances the cough should be evaluated separately from the common cold to determine if an underlying condition may be present.17 Lozenges Anti-inflammatory, antibacterial or anaesthetic lozenges or gargles may help to relieve a sore throat, although they have no effect on the viral infection. Vitamin C18,19,20 High doses of vitamin C have not been shown to prevent colds but may reduce the duration and severity of symptoms. Doses of 2000 mg per day can cause stomach cramps, kidney stones and diarrhoea. Echinacea17,20 It is not known whether echinacea really can prevent or treat colds or flu. This is because most echinacea preparations have not been tested in reliable clinical trials. Therefore, there is no reliable information on how much echinacea a customer would need to take, or how long it should be taken for. “Annual influenza vaccination is strongly recommended for any adult or child (over six months of age) who wishes (or whose parents wish them) to be protected against influenza.” The use of Agrippal, Fluarix, Influvac or Vaxigrip in children aged five years to less than 10 years is strongly preferred; however, Fluvax may be used when no timely alternative vaccine is available and parents are informed of the potential increased risk of fever. Annual immunisation is strongly recommended for older people, pregnant women, those at risk and those who work or live with these vulnerable groups. Immunisation helps to protect against serious complications (such as pneumonia) that may arise as a result of contracting the virus. Immunisation should ideally occur between March and May, before the onset of the flu season. Protection develops about two weeks after the injection and lasts for up to one year. Antivirals Antiviral medicines may also be used to shorten the duration of symptoms and reduce the risk of complications. The antivirals currently available in Australia are the neuraminidase inhibitors: Oseltamivir (Tamiflu) – capsule or powder for oral solution. Zanamivir (Relenza) – inhaled via a diskhaler • They are S4 and only available on a doctor’s prescription. • Treatment must commence within 48 hours of the onset of symptoms. inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 9 John Facts Bell says Behind the Fact Card Colds and flu Pharmacist CPD Module number 238 References • They shorten symptom duration by one day and reduce the time to return to work by half a day.6 • They reduce the incidence of complications. • Common side effects are nausea and vomiting. It is therefore recommended that they are taken with food. Neuraminidase inhibitors are not recommended unless influenza is circulating in the community, when they may be considered only for people at risk of complications. They may be used in institutional prophylaxis and pandemics. They are not recommended for routine prophylaxis against influenza; annual influenza immunisation is recommended to prevent infection. In a small study in immunocompromised people there was no significant difference in the incidence of influenza between people who took a course of oseltamivir compared to those who took placebo. They may be used to prevent influenza in poorly vaccinated communities at risk e.g. when institutional outbreak control is necessary, or at the direction of 10 public health authorities as an adjunct to other measures.6 Symptoms of the flu may be treated as for the common cold. In a small proportion of cases, influenza can lead to: • Secondary bacterial pneumonia – occurs when bacteria invade the lungs. Symptoms include shortness of breath, green or yellow phlegm (mucous), chest pains and a temperature. Death rates are high, but it is less lethal than primary influenza pneumonia. • Primary influenza pneumonia – symptoms include difficulty with breathing and blue discoloration of the skin (cyanosis). • Inflammation of the brain or heart – can occur during recovery from the flu. • Reye’s syndrome – this leads to brain inflammation and liver degeneration and is fatal in between 10 and 40 per cent of cases. Children under 16 years should not be given any medication containing aspirin as it increases the risk of Reye’s syndrome.17 inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 1. Patient.co.uk accessed at: www.patient.co.uk/doctor/upperrespiratory-infections-coryza 2. Cardiff University accessed at: www.cardiff.ac.uk/biosi/ subsites/cold/commoncold.html 3. Merck Manual for Health Care Professionals. Respiratory virus. At: www.merckmanuals.com 4. Therapeutic Guidelines Limited. eTG complete [CD-ROM]. North Melbourne. 5. Better Health Channel Victoria accessed at: www. betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/ flu_influenza?open 6. Gould L. Cold and Flu. InPHARMation. 2007;8(2):6–10. 7. Australian Health Management Plan for Pandemic Influenza Canberra accessed at: www.flupandemic.gov.au/internet/ panflu/publishing.nsf/Content/whatis-1 8. Clinical Knowledge Summaries UK accessed at www.cks. nhs.uk/common_cold/background_information/definition/ transmission 9. WebMD accessed at: www.webmd.com/cold-and-flu/coldguide/colds-risk 10.Helms RA, Quan DJ, Herfindal ET, Gourley DR, et al. Textbook of Therapeutics Drug and Disease Management. 8th ed. Pennsylvania USA Lippincott, Williams & Wilkins. 11.Blenkinsopp A, Paxton P, Blenkinsopp J. Symptoms in the Pharmacy A guide to the Management of Common Illness. 5th ed. Blackwell Publishing Oxford UK. Pages 17–20. 12.Rutter P, Newby D. Community Pharmacy Symptoms, Diagnosis and Treatment. Australian and New Zealand 2nd edn. Sydney: Elsevier; 2012. 13.Therapeutic Goods Administration accessed at: www.tga. gov.au/newsroom/btn-cough-cold-medicines-121126. htm#hprofessionals 14.Mayo Clinic Rochester accessed 18 March 2013 at: www. mayoclinic.com/health/common-cold-in-babies/DS01106/ DSECTION=symptoms 15.Immunisation Handbook 10th edition 2013. 16.Rossi S, ed. Australian medicines handbook. Adelaide: Australian Medicines Handbook; 2012. (Accessed 20/2/2013) At: www.amh.net.au/online/view.php?page=index.html 17.Pharmaceutical Society of Australia. Australian pharmaceutical formulary and handbook. 22nd edn. Canberra: The Pharmaceutical Society of Australia; 2012. 18.Flu smart accessed (3/3/2013) at: http://flusmart.org.au/ about-the-flu/ 19.Douglas RM, Hemila H, Chalker E, et al. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2007; 3:CD000980. 20.National Centre for Immunisation Research and Surveillance (NCIRS). Accessed at: http://ncirs.edu.au/news/2009/ paediatric-influenza-WA-2nd-indigenous-workshop.pdf Colds and flu Pharmacist CPD Module number 238 Facts Behind the Fact Card Assessment questions for the pharmacist Colds and flu Personal ID number: — — — — — — Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assessment due 31 July 2013 Before undertaking this assessment, you need to have read the Facts Behind the Fact Card article and the associated Fact Cards. This activity has been accredited by PSA as a Group 2 activity. Two CPD credits (Group 2) will be awarded to pharmacists with four out of five questions correct. PSA is authorised by the Australian Pharmacy Council to accredit providers of CPD activities for pharmacists that may be used as supporting evidence of continuing competence. Submit online at www.psa.org.au/selfcare 1.The order in which common cold symptoms appear is: 3.The following responses relate to the use of cough and cold preparations in children aged 2–6 years of age. Which ONE response is INCORRECT? a. Cough first; fever second; nasal symptoms last. b. Fever first; sore throat second; nasal symptoms last. c. Nasal symptoms first; sore throat second; cough last. d. Sore throat first; nasal symptoms second; cough last. 2. Which ONE of the following statements best describes the concomitant use of guaifenesin and dextromethorphan? a. This combination is first-line therapy for cough associated with the common cold. b. This combination is not as effective as concomitant use of guaifenesin and codeine. c. This combination generally is considered to be irrational. d. None of the above. up to Circle one correct answer from each of the following questions. Submit answers Fax: 2 CPD Credits GROUP 2 Accreditation number: CS130005 (02) 6285 2869 This activity has been accredited for Group 2 CPD (or 2 CPD credits) suitable for inclusion in an individual pharmacist’s CPD plan. Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600 Please retain a copy for your own purposes. Photocopy if you require extra copies. a. Using cough and cold medications in small children can delay medical advice being sought for more serious illnesses such as asthma, influenza, pneumonia, bronchitis or middle ear infection. b. Possible side effects of cough and cold medications are allergic reactions; increased or uneven heart rate; slow and shallow breathing; drowsiness or sleeplessness; confusion or hallucinations; convulsions; nausea; constipation. c. Overuse of these products or overdose can lead to serious harm. d. There are no issues with their use as children are small adults. 4. Regarding treatment of symptoms of colds and flu which ONE of the following is most correct? a. Oral decongestants are more effective than topical nasal decongestants. b. Oral and nasal decongestants, sedating antihistamines and intranasal anticholinergics may all provide relief from rhinorrhoea. c. Echinacea is effective in reducing symptom duration and severity in children. d. Less-sedating antihistamines are the medicines of choice for rhinorrhoea caused by the common cold. 5. Which ONE of the following antitussives has been approved for use as a cough suppressant for children aged 2–6 years? a. Codeine. b. Dextromethorphan. c. Pholcodine. d. None of the above. inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 11 John BellCounter says Connection Colds and flu Pharmacy assistant’s education Module 238 Colds and flu By Jan Castrisos This education module is independently researched and compiled by PSA-commissioned authors and peer reviewed. The common cold and influenza (flu) are both viral infections. They share many symptoms, and people often use the terms cold and flu as if they were one and the same infection. It is important to know the difference between a cold and the flu to effectively advise customers. Colds are very common – adults can get 2–4 colds per year while children can get as many as 3–12. The common cold and influenza are contagious and are most commonly spread by respiratory droplets from sneezing or coughing. Ear, Nose & Throat 1117 2011 Coughs The common cold, allergy and cigarette smoke are common causes of coughing, but a cough can also be a symptom of a serious illness or a side effect of a medicine. Treatment for a cough depends on its cause. Coughingisanormalreflextoprotect and clean our airways (respiratory tract). Coughingclearsirritatingmaterial(e.g., smokeordust)andexcesssecretions (mucus,sputum,phlegm)fromour throat,airpassagesandlungs.The sound and pattern of a cough depends on its cause. Causes of coughing Cough is a symptom of a range of medical conditions and sometimes a person may have more than one reason for coughing. Ear, Nose and Throat 0086 Cold and Flu Common colds and the ‘flu’ (influenza) are viral infections affecting the nose, sinuses, throat and airways. Antibiotics do not work against these viral •Asthma infections, but colds and the flu usually get better on their own. •Respiratorytractinfections(e.g.,colds, Medicines may relieve some of the uncomfortable symptoms of colds and flu. bronchitis,croup,whoopingcough, pneumonia) •Inhaledirritants(e.g.,cigarettesmoke, Causes of coughing include: dust,fumes,aforeignbody) When someone has a cold or flu, •Postnasaldrip(catarrh)–excessnasal the•Lungdisease(e.g.,cysticfibrosis, fluid from their nose, mouth secretions which run down into the and COPD,cancer) airways contains the infecting backofthethroat.Oftencaused •Gastroesophagealreflux(heartburn) virus. Colds and flu spread when this byallergy,commoncoldsorsinus – stomach acid rises up into the infected fluid passes to someone-else infection and triggers coughing (e.g.,oesophagus by touch, coughing, sneezing). Colds spread easily, especially between children who spend a lot of time Self Care is a program of the Pharmaceutical Society of Australia. together (e.g., at childcare or school). Self Care is committed to providing current and reliable health information. A cold is most infectious in the first one or two days after symptoms develop. •Coughing •Mildfever •Headache •Tiredness. Flu (influenza) symptoms are similar to cold symptoms, but are usually more severe and may also include: •Highfevers,sweatingandshivering •Achingmusclesandjoints •Weaknessandlethargy Signs and symptoms •Lossofappetite,nauseaandvomiting. Cold symptoms include: Cold and flu symptoms usually go within 10 days, although a cough may last longer. •Runnynose •Blockednose(congestion) •Sorethroat •Red,wateryeyes •Sneezing Protection against influenza A‘fluinjection’willgiveprotection againstthe‘flu’.Vaccination,before the‘flu’seasonstartseachyear,is Self Care is a program of the Pharmaceutical Society of Australia. Self Care is committed to providing current and reliable health information. Related Fact Cards Colds and flu Coughs Ear problems Sinus problems Pain relievers 12 2011 Customers will frequently come into the pharmacy asking for cold and flu medicine. Pharmacy assistants should be aware of what questions to ask, when it is appropriate to recommend a product and when they should refer a customer to the pharmacist. What is the difference between the common cold and the flu? Unlike the common cold, the onset of symptoms for flu is very sudden and fast. While a cold and the flu are both infectious viral illnesses, cold symptoms are usually mostly around the nose and head. The flu is much more severe, with symptoms such as fever, chills and body aches. A person suffering from the common cold can generally walk about and work but a flu patient usually does not feel like getting out of bed. How is the cold and flu spread? The common cold and flu are contagious and are most commonly spread by respiratory inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. droplets from sneezing or coughing. They can also be spread by shaking hands with an infected person with poor handwashing techniques (small children), then touching the eyes, nose or mouth after coming in contact with the virus. Some viruses live on surfaces such as door handles and table surfaces for up to two hours. What are the symptoms of a cold? The common symptoms of a cold are: • • • • • • blocked nose (congestion) runny nose sneezing tired and generally feeling unwell mild temperature (occasionally) mild sore throat, hoarseness and cough. Symptoms generally peak after 2–3 days, and then gradually clear. However, the cough may persist for up to four weeks after the infection has gone due to inflammation in the airways that can take a while to clear. Flu symptoms are more severe. These include fever, chills, muscle aches and pains and headaches. Colds and flu Pharmacy assistant’s education Module 238 Influenza or the common cold? Symptom Common cold Influenza Severity Usually not severe Serious problems can occur such as pneumonia Speed of onset Gradual Sudden Fever None to mild Usually high – lasts 3– 4 days General aches None to slight Usual – often severe Tiredness and weakness Mild Usual – may last 2–3 weeks Headache None to mild Yes Exhaustion Rare Yes and starts early Stuffy nose Common Sometimes Sore throat Sometimes Common Sneezing Usual Sometimes Cough, chest discomfort Mild Common, can become severe What is the role of the pharmacy assistant? You need to understand the legal and professional requirements for supplying a Pharmacy medicine (S2) and Pharmacist Only medicine (S3) to ensure the safe and appropriate supply of non-prescription cold and flu medicines. It is important to gather as much information as possible. A good approach is to have a conversation with the person and show them that you really do care about helping them manage their symptoms. Often they will tell you the information you need if you ask a few open questions and listen carefully to the answers. If you are uncertain or something doesn’t make sense, always refer to the pharmacist. Use the WHAT STOP GO protocol on page 14 to help decide how best to help customers and who should be referred to the pharmacist. If your customer directly requests a particular product it is wise to firstly ask if this product has worked for them before with an open ended question. For example ‘You’ve had this product before, how did it go for you?’ This allows you to establish why the customer is requesting a particular product. Cold and flu treatments There is no magic cure for the common cold. There is no treatment that will shorten the length of the infection. Treatment aims to ease symptoms whilst the immune system clears the virus. On 1 September 2012 the following changes were made to the recommendations for the Counter Connection provide reassurance that cold symptoms, while annoying and at times uncomfortable, are not dangerous and will go away in time. Some explanations for the changes to the recommendations are: Over-the-counter (OTC) cough and cold medicines do not work for children younger than six years and in some cases may pose a health risk especially as serious complications may be missed. sale of cough and cold medicines in children. • Cough and cold medicines should not be given to children under six years of age. • Cough and cold medicines should only be given to children aged 6–11 on the advice of a doctor, pharmacist or nurse practitioner. Most useful advice The most useful advice for adults and especially for children up to the age of 11 years is: • Stay home and rest. • Use paracetamol or ibuprofen for fever, sore throats, aches and pains. • A fever can lead to mild dehydration due to sweating, causing tiredness and headache. Advice is to drink plenty of fluids such as water, fruit juices and clear soups. • Steam inhalations (e.g. humidifiers) help clear mucus and clear a blocked nose. It is a temporary effect, but may be useful before bedtime (especially for children) to help them get off to sleep. Although there is no scientific evidence that addition of substances such as menthol or eucalyptus oil to inhaled steam provide any additional benefit, they may provide a placebo effect. They should be used at a dilution of five mL to approximately 500 mL of hot water. • Saline nasal sprays or drops (e.g. Little Noses, Fess, Narium) may help thin nasal secretions while avoiding the risk of rebound congestion that decongestant nasal sprays can cause. Saline nasal drops are a good alternative for young children and babies. When responding to concerned parents about treating their child, it is important to The efficacy and risk of such medications needs to be studied in children. The doses are determined by assuming that children are ‘little adults’. If a medicine is to be used in children, it should be studied in children. Cough and cold medications should not be exceptions to this rule. OTC cough and cold medicines Decongestants Decongestants are the medicines of choice for a blocked or runny nose. They can be taken orally or administered in the form of nasal sprays or drops. Oral decongestants (e.g. pseudoephedrine, phenylephrine) and nasal sprays or drops (e.g. oxymetazoline, xylometazoline) may be taken for short term relief of a runny or blocked nose. Antihistamines Antihistamines are classed as sedating and less-sedating. Sedating antihistamines (e.g. chlorpheniramine, dexchlorpheniramine, diphenhydramine, promethazine) may help relieve a runny nose but can cause sedation and drowsiness. These products are S3 and referral to the pharmacist is required for supply. Less-sedating antihistamines (e.g. loratadine, cetirizine, desloratadine) are indicated for allergic rhinitis and not effective for treating a cold. Cough medicines Cough medicines are either expectorants or suppressants. Expectorants (e.g. bromhexine, guaiphenesin) help bring up mucous from the airways. They help make coughing easier as they thin the mucous making the cough more productive. Suppressants (e.g. codeine, dextromethorphan, dihydrocodeine, inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 13 John BellCounter says Connection How to correctly give medication to children • Give a dosage according to the child’s weight, not age. Have the pharmacist check it is correct. • Always measure the medicine with a dropper, dosage cup or other accurate measuring device. Kitchen teaspoons used for cooking are not accurate. One metric teaspoon = five mL. • Paracetamol or ibuprofen may be given with other medicines, such as antibiotics or OTC cold medicines. Make sure the OTC cold medicine does not already contain paracetamol or ibuprofen; otherwise the child may be given a double dose. Do not give OTC cold medicines to children younger than 12 years of age unless instructed to do so by the pharmacist. • Liquid medicines may be mixed in with soft foods or liquids. Chewables may be crushed and added to food, such as yoghurt, applesauce and peanut butter. Mix the medicines with a small amount of food or drink, so you can be sure the child takes it all. Why no antibiotic? An antibiotic is not needed if a virus is causing an infection like the common cold and flu. This is because: • Antibiotics do not kill viruses. Antibiotics only kill bacteria. • Antibiotics may cause side-effects such as diarrhoea, rashes, thrush, feeling sick. • Overuse of antibiotics when they have not been necessary has led to some bacteria becoming resistant to them. This means that some antibiotics might not be as effective when they are really needed. Colds and flu Pharmacy assistant’s education Use the What Stop Go protocol to decide when to refer What Stop Go Refer to the pharmacist. Who is the patient? Children less than 12 years (new recommendations) Elderly- conditions such as bronchitis and pneumonia may co-exist Pregnant or breastfeeding How long have the symptoms been present? Recurring persistent or deteriorating symptoms such as cough lasting longer than 2 or 3 weeks Actual Symptoms – what are they? Wheezing or a harsh barking cough Cough which is worse morning, night or after exercise Severe cough followed by a whoop Mucus is blood stained or has a bad odour Fever or fever with a rash Treatment for this or any other condition? (e.g. other medicines and conditions) Existing medicines may cause cold or flu like symptoms (e.g. cough) There are some important interactions between some medicines and some conditions and cough and cold preparations Symptoms or side effects caused by other conditions and/or medicines? Symptoms or side effects caused by other medicines Existing medical conditions Existing allergies Totally sure? If you are unsure, refer to the pharmacist Requested product is not appropriate or you are unsure Overuse – how often has the patient been taking the medicine or self-treating the condition? Suspect misuse or abuse Pharmacist preferred? Customer requests to speak to the pharmacist Requested product is a Pharmacist Only medicine or you believe a Pharmacist Only medicine is appropriate for the customer GO – refer to the pharmacist Go ahead and treat if any of the above conditions are not an issue otherwise refer to the pharmacist. pholcodine) are meant to decrease coughing. Because coughing is a natural response to substances in the lungs they should be avoided in people suffering from certain airways diseases especially in children and should be referred to the pharmacist. Echinacea Cough products are generally not effective in relieving coughs caused by a cold. Combination products containing both expectorants and suppressants should be avoided. Flu treatments Lozenges Anti-inflammatory, antibacterial or anaesthetic lozenges or gargles may help to relieve a sore throat, or a cough, although they have no effect on the viral infection. For a child aged four years and older, cough drops or lozenges may help soothe the throat. Remember not to give cough drops or lozenges to a child younger than four years because of the risk of choking. Dose on the package should be strictly adhered to. Vitamin C High doses of vitamin C may reduce the duration and severity of symptoms, but doses of 2000 mg or more per day can cause stomach cramps and diarrhoea. 14 Module 238 inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. It is not known whether echinacea really can prevent or treat colds or flu. This is because most echinacea preparations have not been tested in reliable clinical trials. Symptoms of the flu may be treated as for the common cold. Antiviral medicines may also be used to shorten the duration of symptoms and reduce the risk of complications. The antivirals currently available in Australia are oseltamivir (Tamiflu) and zanamivir (Relenza). They are Prescription only (S4) and require a doctor’s prescription. Prevention of cold and flu Another difference between the common cold and the flu is that the flu may be preventable. Every year, only a handful of strains of the influenza virus cause most of the flu across the world. Annual influenza vaccines are available. While the vaccine is fairly effective, unanticipated flu strains can evolve against which the vaccine will not work. Colds and flu Pharmacy assistant’s education Module 238 Counter Connection Assessment questions for the pharmacy assistant Colds and flu Personal ID number: — — — — — — Full name:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pharmacy:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suburb:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . State:.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postcode:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Circle one correct answer from each of the following questions. Before undertaking this assessment, you need to have read the Counter Connection article and the associated Fact Cards. The pass mark for each module is five correct answers. Participants receive one credit for each successfully completed module. On completion of 10 correct modules participants receive an Achievement Certificate. 1. Cold symptoms: a. Usually start suddenly. b. Commonly include a high fever. c. Usually start with discomfort in the nose or throat. d. Usually last for two weeks. 2. Which ONE of the following statements relating to the sale of cough and cold medicines in children is correct? a. Cough and cold medicines should only be given to children aged 6–11 years on the advice of a doctor, pharmacist or nurse practitioner. b. Cough and cold medicines should not be given to children aged 6–11 years. c. Cough and cold medicines should only be given to children aged 2–6 years on the advice of a doctor, pharmacist or nurse practitioner. d. There are no changes to the recommendations for children aged between 6–11 years. 3.The mother of a two-year-old has requested some advice for her child Assessment due 31 July 2013 who is sneezing a lot with benign prostatic hyperplasia. d. An adult customer with a raspy dry throat and blocked nose and who is not taking any other medications. Submit answers Submit online at www.psa.org.au Fax: (02) 6285 2869 Mail: Self Care Answers Pharmaceutical Society of Australia PO Box 42 DEAKIN WEST ACT 2600 5. When discussing the dose of paracetamol which ONE of the following statements is correct? Please retain a copy for your own purposes. Photocopy if you require extra copies. who is unwell. You ask her a number of questions and find that her child has the symptoms of the common cold. Which ONE of the following statements contains the most appropriate advice to give this mother? a. Paracetamol can be given for the fever, saline nose drops for the blocked nose and pholcodine for the cough. b. Paracetamol can be given for the fever, saline nose drops for the blocked nose and lozenges for the cough. c. The child should be kept at home and rest. Saline nose drops can be used for a blocked nose and paracetamol can be given for a fever. d. Ibuprofen can be given for the fever, dexchlorpheniramine (Polaramine) for the runny nose and pholcodine for the cough. 4. Which one of the following customers does NOT require referral to the pharmacist? a. A child aged 7–12 years of age. b. A customer with a slight fever and blocked nose taking blood pressure medication. c. A customer with a mild headache a. Five mL of liquid can be measured using a regular teaspoon. b. The dose should be calculated using the child’s weight and checked by the pharmacist. c. Liquid ibuprofen must not be mixed in yoghurt. d. Children’s paracetamol tablets cannot be crushed. 6.The mother of a three-year-old child has requested a bottle of phenergan (promethazine). The family is leaving on an overseas flight the next day and she wants it to help the child sleep. She gave it to the child on her last flight six months ago but discarded the remainder as she thought she no longer needed it. Which ONE of the following is the correct response? a. The customer cannot have the medication as the child is less than 6 years of age. b. The customer can have the medication as it is not being used for a cold so you supply the medication with counseling on the appropriate dose. c. The customer can have the medication as it is not being used for a cold so you refer the customer to the pharmacist as it is an S3. d. There is no problem with supplying this medication as it is an S2. inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. 15 Members notice board John Bell says & Self Care achievers Self Care achievers Self Care presents certificates to staff who successfully complete a year of Counter Connection modules. Year 5 Jacki Perrett Judy Hastings Sunayna Odhavji Nola Woodward Nadine Kearney Kelly Mudford Faye Thompson We would like to congratulate the following people who have received the following: Jeremy Huggins Sarah Reay Elizabeth Graovac Katrina Leader Carla Rauchle Alex Clarke Karen Morris Linda McKeddie Kristina Smith Julie Henley Tara Black Erin Taylor Year 4 Year 2 Nathalie Van Der Houwen Kate Lieschke Year 12 Olga Missaghian Shilaja Thekkute Year 7 Maree Rudder Dolores Cardona Year 11 Glenda Gaskell Kerrie Lowry Carlita McConnell Heather O’Sullivan Julie Davis Dianne Kuhnemann Kelly Matthews Year 9 Sandra Baird Raelene Rivett Stacy Sapienza Louise Runnalls Selina O’Halloran Olga Katsoulis Annie Hubbard Tanya Lehane Helen Campbell Kerry-Anne Purvis Tom Adamson Tanya Curtis Sheila Thorsen Cheryl Kimmince Kelly Holdsworth Jessica Presland Deborah Heinrich Sue Brown Tammy McLaren Stacey Folau Lucy Cowie Susie Moretta Fran Begley Jane Rutherford Year 6 Julie Killen Huriye Irfanli Tracy Bacon Cathy Butta Esther Kok Dylan Hunt Rachel Webb Sandy Ballenhagen Lauren Mather Candace Clement Daniela Egloff Cath Semmler Jemma Newtown Rosemary Brenton Year 8 Deborah Lang Year 3 Ilinka Perntoska Jan Cronin Antonietta Barracu Virginia Woodbridge Assia Baban Debra Russell Ashley Way Year 1 Sue Loip Lynelle Miller Theresa Grimsey Helen Nakos Bev Holliday Faye Soya Conferences and calendar dates Conferences Conferences WineHealth 2013 Pharmacy Australia Congress 2013 18 – 21 July Sydney Convention and Exhibition Centre Sydney, NSW www.winehealth.com.au 10 – 13 October Brisbane Exhibition Centre, Qld www.psa.org.au/pac Enhancing optimal pharmaceutical care through technology 12th Commonwealth Pharmacists Association and the 33rd Caribbean Association of Pharmacy Conference 11–18 August The Atlantis Hotel, Nassau Bahamas www.pharmacybahamas.com 4th Global Drug Safety Conference & Exposition 14 – 16 October Brisbane Exhibition Centre, Qld www.psa.org.au/gds13 AMSI Conference 2013 14 November Details to be announced PSA Victorian Clinical Weekend 24 – 25 August Wyndham Resort, Torquay, Victoria International Pharmaceutical Federation (FIP) World Congress 2013 31 August – 5 September Dublin, Ireland www.fip.org/dublin2013 National health calendar dates June 2013 10 – 16 Mens Health Week www.menshealthweek.org.au July 2013 JulEYE Eye Health Awareness Pharmacy 2013 4 – 7 September Sheraton Mirage Port Douglas, Qld www.pharmacyconference.com.au www.eyefoundation.org.au 14 – 20 National Diabetes Week www.diabetesaustralia.com.au 22 – 28 National Pain Week www.chronicpainaustralia.org 16 inPHARMation June 2013 I © Pharmaceutical Society of Australia Ltd. Christina Cortese What’s coming up in inPHARMation Next month’s inPHARMation will cover the topic of wound care in the pharmacy. Pharmacists are frequently asked for advice on how to treat various wounds, ranging from cuts and grazes, to burns and blisters, to post-surgical wounds and more. Pharmacists are well placed to appropriately treat many wound presentations and thereby help to reduce some of the pressure on hospital emergency departments. The article will explain wound healing, the management of a variety of wounds, including dressing selection and the triggers for referral. Together with some treatment tips, the article looks at some common medicines that affect wound healing.